Evaluation of acute kidney injury after surgery for congenital heart disease in neonates: a tertiary hospital experience.

PURPOSE OF THE ARTICLE: Acute kidney injury (AKI) after cardiac surgery in children with congenital heart disease (CHD) is a serious complication closely associated with high morbidity and mortality. Despite numerous studies on AKI in children, most studies have excluded neonates. We sought to characterize AKI associated with cardiac surgery in neonates, determine its incidence, perioperative and postoperative risk factors, and short-term results. MATERIALS AND METHODS: This retrospective study included 177 neonates who were operated on for CHD in our hospital between January 2015 and December 2019. Data of the patients were analyzed according to nKDIGO (neonatal Kidney Disease Improving Global Outcomes) and nRIFLE (neonatal Risk, Injury, Failure, Loss of function, End-stage kidney disease) criteria for evaluating AKI retrospectively. Data of groups with and without AKI were analyzed. RESULTS: The average age of 177 neonates were 8.2 ± 6.1 (1-28) days. Twenty-two (12.4%) neonates had CS-AKI defined according to nKDIGO criteria. Four (2.3%) neonates reached nKDIGO stage I, 1 (0.6%) reached stage II, 17 (9.6%) reached stage III. Thirty-eight (21.5%) neonates had CS-AKI defined according to nRIFLE criteria. Twenty-four (13.6%) neonates reached nRIFLE stage risk(R), 6 (3.4%) reached stage injury(I), 8 (4.5%) reached stage failure (F). The incidence of cardiac surgery-associated acute kidney injury (CS-AKI) in neonates was 12.5% and 21.5% for nKDIGO and nRIFLE, respectively. The percentage difference between nKDIGO and nRIFLE for AKI assessment was due to the criteria for nRIFLE stage risk(R) urine output < 1.5 mL/kg/h for 24 h. In both classifications, the duration of cardiopulmonary bypass, operation, inotropic treatment, and mechanical ventilation, length of intensive care unit (ICU), and hospital stay were significantly higher in the AKI group than those without AKI group (p˂.05). The mortality rate in the groups with AKI was found to be significantly higher (p˂.05) than in the groups without AKI. In Kappa analysis, when two classifications were compared according to AKI stages, a significant agreement was found between nKDIGO and nRIFLE classifications (p˂.05) (Kappa: 0.299). CONCLUSION: AKI and mortality rates were similar between groups according to the nKDIGO and nRIFLE criteria. For early prediction of AKI and adverse outcomes, diagnostic reference intervals might be specified in more detail in neonates undergoing cardiac surgery for CHD.

Neurologic Complications After Pediatric Heart Transplant: A Single-Center Experience.

OBJECTIVES: Neurologic complications that can lead to serious mortality and morbidity in pediatric heart transplant recipients have been reported to range from 23.6% to 45%. In this study, the frequency, time, cause, and characteristics of neurologic complications in pediatric heart transplant recipients were evaluated. MATERIALS AND METHODS: We retrospectively reviewed data of 37 pediatric heart transplant recipients aged <18 years who were seen at our hospital between 2007 and 2017. Medical records were reviewed to identify neurologic complications. Clinical features were compared between pediatric heart transplant patients with and without neurologic complications. RESULTS: The rate of posttransplant neurologic complications in pediatric heart transplant was 27% (10/37). Median age of patients with neurologic complications was 12 years (range, 11-18 years). Median time for neurologic complications was 3 days (range, 2-46 days). Primary diagnoses of these 10 recipients were dilated cardiomyopathy (n = 7) and restrictive cardiomyopathy (n = 3). There were no significant differences between recipients with and without neurologic complications (P > .05).The etiologies of neurologic complications were posterior reversible encephalopathy syndrome in 3 patients (8.1%), stroke in 2 patients (5.4%), peripheral neuropathy in 2 patients (5.4%), hypertensive encephalopathy in 1 patient (2.7%), and drug encephalopathy in 1 patient (2.7%). CONCLUSIONS: Neurologic complications may lead to serious mortality and morbidity in pediatric heart transplant patients. Seizures, posterior reversible encephalopathy syndrome, stroke, peripheral neuropathy, transient ischemic attack, and cerebral infections are the most common neurologic complications, which are seen in the perioperative period in particular. Careful follow-up of pediatric heart transplant patients, with detection and early treatment of neurologic findings, will contribute to lower rates of sequelae. To our knowledge, this is the largest study to show a detailed experience of neurologic complications in pediatric heart transplant patients from a single center in Turkey.

Coronary artery fistulae and treatment in children.

BACKGROUND AND OBJECTIVES: In this study, we aimed to review the treatment options and long-term problems of patients who were diagnosed with coronary artery fistulae (CAF) in our institution. We also tried to determine the most appropriate time for treatment of this condition. METHOD: From 2000 to 2018, the medical records of 56 patients (33 males and 23 females) who had CAF diagnoses were retrospectively reviewed. RESULTS: The mean age of the patients at the time of diagnosis was 3.9 ± 4.6 years (range, 1 month to 18 years) and the mean duration of the follow-up period was 7.4 ± 4.5 years (range, 1 year to 17.5 years). The right coronary artery (RCA) was the most common origin site for CAF, the left main coronary artery (LMCA) was the second most common origin site whereas the left anterior descending coronary artery (LAD) was the third most common origin site. Catheter angiography showed that right ventricle (RV) was the site of termination for CAF in 23 patients (41.1%) while the CAF drained to the pulmonary artery in 16 patients (28.6%). Transcatheter intervention was performed in ten patients, while CAF were corrected surgically in five patients. Transcatheter intervention was initially attempted in two out of the five surgically-treated patients, but the procedure was unsuccessful. A vascular plug was deployed in six patients, a platinum coil was used in three patients, and a platinum coil with tissue adhesive was placed in one patient using a catheter. Early complications were seen in two patients during transcatheter intervention and in one patient during surgery. There were no instances of death or late complications in patients treated surgically or via transcatheter. CONCLUSIONS: Coronary artery fistulae are usually asymptomatic, and medical therapy with long term follow up is the first line treatment. Fistulae that cause hemodynamically significant shunting, chamber enlargement, or visible symptoms should be closed at an early age. This study shows that transcatheter closure is a safe treatment option for CAF that may be performed with high success. Also, it should be known that surgery may be performed effectively with low rates of complications. Because complications can develop in treated and untreated patients of all ages, follow-up should occur during the patient`s lifetime.

Management of pediatric cardiac transplantation candidates with pulmonary hypertension and high pulmonary vascular resistance.

BACKGROUND AND OBJECTIVES: Right ventricular failure is an important cause of mortality and morbidity after orthotopic heart transplantation (OHT). The right ventricle of the donor may fail to accommodate to the high pulmonary vascular resistance (PVR) of the recipient. Pulmonary hypertension (PH) due to chronic heart failure with PVRi > 4 Wood units.m2, transpulmonary gradient > 15 mmHg adversely affect the outcome of OHT. In this study we aimed to evaluate management strategies in our pediatric cardiac transplantation candidates with PH and high PVR prior to OHT. METHOD: Twenty-six cardiac transplantation candidates (age: 10.2 ± 4.6, 1-17 years) underwent cardiac catheterization for the determination of PVR and pulmonary arterial pressure. They were admitted to the hospital and received 1-3 days of intravenous (IV) vasodilator therapy; 0.5-3 µg/kg/min nitroglyserin and/or 0.5-3 µg/kg/min nitroprusside, 5-15 µg/kg/min dobutamin and/or dopamin to keep systolic blood pressure above 80 mmHg. RESULTS: Thirteen patients had dilated cardiomyopathy (CMP), 11 had restrictive CMP, one had hypertrophic CMP and one had congenital heart disease (CHD). Nineteen of the 26 patients underwent OHT. Mean pulmonary arterial pressure of the patients ranged between 11 and 82 mmHg (30.4 ± 16 mmHg) and PVRi between 0.41-21.4 Wood units.m2 (5.3 ± 5.7). Nine patients had PVRi above 4 Wood units.m < sup > 2 < /sup > . Six of these patients had IV treatment for longer than three days and some received specific anti-PH treatment. Eventually they underwent a pulmonary vasoreactivity test with IV iloprost and six had PVRi < 4 Wood units.m < sup > 2 < /sup > . Five of them underwent OHT. CONCLUSION: Cardiac transplantation candidates with PH and high PVR should be evaluated after conditioning with vasodilator and inotropic treatment. Specific treatment for PH and vasoreactivity testing may help selected patients reenter the transplantation list.

Early and late outcomes of surgical repair of double-chambered right ventricle: a single-centre experience.

OBJECTIVE: Double-chambered right ventricle is characterised by division of the outlet portion of the right ventricle by hypertrophy of the septoparietal trabeculations into two parts. We aim to report our experiences regarding the presenting symptoms of double-chambered right ventricle, long-term prognosis, including the recurrence rate and incidence of arrhythmias after surgery. METHODS: We retrospectively investigated 89 consecutive patients who were diagnosed to have double-chambered right ventricle and underwent a surgical intervention from 1995 to 2016. The data obtained by echocardiography, cardiac catheterisation, and surgical findings as well as post-operative follow-up, surgical approaches, post-operative morbidity, mortality, and cardiac events were evaluated. RESULTS: Median age at the time of diagnosis was 2 months and mean age at the time of operation was 5.3 years. Concomitant cardiac anomalies were as follows: perimembranous ventricular septal defect (78 patients), atrial septal defect (9 patients), discrete subaortic membrane (32 patients), right aortic arch (3 patients), aortic valve prolapse and/or mild aortic regurgitation (14 patients), and left superior caval vein (2 patients). The mean follow-up period was 4.86 ± 4.6 years. In these patients, mean systolic pressure gradient in the right ventricle by echocardiography before, immediately, and long-term after surgical intervention was 66.3, 11.8, and 10.4 mmHg, respectively. There were no deaths during the long-term follow-up period. Surgical reinterventions were performed for residual ventricular septal defect (2), residual pulmonary stenosis (1), and severe tricuspid insufficiency (1). CONCLUSION: The surgical outcomes and prognosis of double-chambered right ventricle are favourable, recurrence and fatal arrhythmias are unlikely in long-term follow-up.

The results of interventional catheterization in infants weighing under 2,000 g.

BACKGROUND: The aim of this study was to evaluate the early and mid-term results of interventional cardiac catheterization and procedure-related complications in infants weighing <2,000 g. METHODS: Between May 1998 and April 2017, 22 patients (14 males, 8 females; mean age 14±8.4 days; range, 1 to 30 days) weighing <2,000 g who underwent a total of 23 interventional cardiac catheterization were retrospectively analyzed. Procedures were balloon coarctation angioplasty in 14, balloon atrial septostomy in five, balloon aortic valvuloplasty in one, balloon pulmonary valvuloplasty in one, patent ductus arteriosus closure in one, and stent placement in the ductus in one patient. Another patient underwent balloon coarctation angioplasty and balloon aortic valvuloplasty in the same session. RESULTS: The overall success rate of the interventional procedures was 95.6%. The mean follow-up was 3.2±1.6 years (range, 1 to 5.5) for 18 patients with available records. The rate of serious complications was 18%. The most frequent complications in the early period were low hemoglobin levels requiring erythrocyte suspension transfusion (54.5%) and vascular injury (54.5%). Two patients required reintervention, one patient required surgery after the second intervention, and three patients required only surgery. Six patients underwent palliative interventional procedures, and interventional procedures led to definitive treatment in five patients. CONCLUSION: The mortality and morbidity rate of surgery is high in premature under 2,000 g infants and interventional heart catheterization can be life-saving in this patient group, although it is associated with significant complications in low birth weight newborns.

Diagnosis and surgical treatment of aortopulmonary window: Our single-center experience.

BACKGROUND: In this study, we aimed to report our single-center experience in aortopulmonary window and review clinical signs, symptoms, surgical correction techniques, and long-term outcomes. METHODS: We retrospectively reviewed the medical records of a total of 30 patients who were followed with the diagnosis of aortopulmonary window in our hospital between May 1998 and June 2016. The clinical characteristics of the patients, echocardiographic and angiographic findings, surgical treatment outcomes, and medical problems during follow-up were reviewed. RESULTS: The most common signs and symptoms were murmur, dyspnea, tachypnea, growth retardation, and signs of congestive heart failure. The mean age at the time of surgery was 8.2±14.4 months (7 days to 60 months). Eighteen patients (60%) had additional congenital cardiac anomalies. Eleven patients had simple congenital heart diseases, and seven patients had complex congenital heart diseases. Four patients were unable to be operated due to Eisenmenger syndrome (n=3) and complex congenital heart disease (n=1). No early or late postoperative death was observed. The mean follow-up was 6.4±4.8 years (range, 5 months to 16 years). In addition to aortopulmonary window repair, an additional cardiac anomaly modifying surgical intervention was corrected in nine patients (34.6%). One patient was reoperated for residual aortopulmonary window and another patient for pulmonary stenosis (valvular, supravalvar) after three years. One of these patients underwent pulmonary balloon valvuloplasty after two years. The reoperation rate was 7.7% (n=2) during follow-up. CONCLUSION: Aortopulmonary window is a rare cardiac anomaly which may be overlooked by echocardiographic study, and which is amenable for repair with low-surgical risk. It is, therefore, imperative to diagnose and treat this condition, before pulmonary vascular disease develops.

Duplicate mitral valve in an infant with Shone's anomaly.

Duplication of mitral valve is a very rare anomaly. It is characterized by two independent mitral valve apparatuses (leaflets and annulus) and subvalvular apparatuses (chordae and papillary muscles) that function well by themselves. In this report, we present duplicate mitral valve with parachute chordal attachment and mitral stenosis in an infant. The patient was successfully treated with the reconstruction of the larger valve without any intervention to the smaller one.